Presentation on theme: "Using the 5 A’s to help women quit"— Presentation transcript:
1Using the 5 A’s to help women quit Young Women & TobaccoUsing the 5 A’s to help women quit
2AcknowledgementsThis training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch.This material was developed through support provided by the Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).
3AcknowledgementsMany thanks to these agencies and individuals for their generosity in sharing their resources in the area of tobacco cessation for women:The American College of Obstetrics and GynecologyThe North Carolina Health and Wellness Trust FundThe UNC Center for Maternal & Infant HealthJudy Ruffin, Women’s Health Branch, NC Division of Public HealthTish Singletary, Director of Training, NC Health & Wellness Trust FundSpecific resources used to guide the development of this training:Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit.You Quit Two Quit. Smoking Cessation: An Essential Maternal Child Health Intervention. ACOG Practice Bulletin, December 2009.The National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t).
4Young Moms ConnectBrings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategiesOne component of Young Moms Connect is training for health care providers on six maternal and child health best practicesHave local coordinator say a few words about the project in the local county at this point, if available.
5MCH Best PracticesEarly entry and effective utilization of prenatal careEstablishment and utilization of a medical home (for non-pregnant women)Reproductive life planningTobacco cessation counseling using the 5 A’s approachPromotion of healthy weightDomestic violence preventionWe’ll talk about this one today.
6ObjectivesIncrease provider understanding about how smoking cessation relates to opportunistic preconception health counselingIncrease provider awareness about trends in smoking before, during and after pregnancy (also by county) and the influencing role of the health care providerIncrease provider awareness about the need for tobacco cessation in high need populations to improve birth outcomes
7Objectives (continued) Improve provider counseling using the 5 A’s approach with all young women of childbearing age (and how this can be adapted for pregnant women who are ready and those who are not)Improve service delivery to extend provider practice standards for smoking cessation counseling services to 12 months postpartumImprove service delivery to address postpartum “relapse”
8Objectives (continued) Increase provider awareness of reimbursement options for tobacco cessation counseling and pharmacotherapy optionsIncrease provider awareness of resources for patients and providers for smoking cessation
9What is preconception care? Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conceptionTimely counseling about risks and strategies to reduce the potential impact of the risksRisk reduction strategies consistent with best practicesPreconception refers to a woman’s health status and risks before a first pregnancy or shortly before any pregnancyCDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
10Components of preconception care Giving protection(i.e.: folic acid, immunizations)Managing conditions(i.e.: diabetes, maternal PKU, obesity, hypertension, hypothyroidism, STIs)Avoiding exposures known to be teratogenic(i.e.: medications, alcohol, tobacco, illicit drugs)Today we will be discussing how to help women prevent a poor birth outcome by avoiding their fetus’s exposure to tobacco.Definition of Teratogenic: Anything that is able to disturb, interrupt or compromise the growth of the fetusCDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
11“Opportunistic” carePreconception care is for every woman of childbearing potential every time she is seenEvery woman, every timeThis is not necessarily doing more; it’s reframing the things you already do every day with the long-term lens of healthy women for healthy pregnancies for healthy birth outcomes and healthy women.Opportunistic care: provide counseling at every visit (sick, wellness, chronic condition, pediatric visit, prenatal, post-partum etc.)CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)
12Every woman, every time Young women who are at risk of pregnancy Young women who are pregnantYoung mothers who are postpartumYoung mothers who are between pregnancies
13Preconception health: Tobacco cessation Smoking during pregnancy is the most modifiable risk factor for poor birth outcomesFor women who may become pregnant and who smoke, provide opportunistic care about tobacco cessationFor women who are pregnant, use prenatal visits to reduce/eliminate tobacco useFor post-partum women, use the post-partum period to re-assess and assist women with tobacco cessationACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking Self Instructional Guide and Toolkit. An Educational Program from the American College of Obstetricians and Gynecologists (ACOG). ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.
14Maternal smoking during pregnancy Increased risk for mother of:Preterm birthEctopic pregnancyPlacental complicationsSpontaneous abortionStillbirthSerious implications for the mother of smoking during pregnancy…Smoking is causally associated with fetal growth restriction, and increasing evidence also suggests that smoking may cause stillbirth, preterm birth, placental abruption, and possibly also sudden infant death syndrome. Smoking during pregnancy also is generally associated with increased risks of spontaneous abortions, ectopic pregnancies, and placenta previa and may increase risks of behavioral disorders in childhood.Additional reference:Women and smoking: A report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001.Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res (2004)
15Maternal smoking during pregnancy Increased risk for child of:Low birth weight (causal association – twice as likely in smokers)1Sudden Infant Death Syndrome1Childhood respiratory illnesses2Learning disabilities and conduct disorders1If it were possible to eliminate smoking during pregnancy entirely, the infant mortality rate in North Carolina would drop 10-20%.3We all are aware that smoking during and after pregnancy is associated with fetal and infant risks .Cigarette smoke doubles a woman’s risk of having a low birth weight baby, as well as increases the risk for pre-term birth and SIDS.Birth weight, SIDS, learning disabilities:Women and smoking: A report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001.Respiratory illnesses:Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): (July 1997)Tager IB, et al., "Maternal smoking during pregnancy: effects on lung function during the first 18 months of life, American Journal of Respiratory and Critical Care Medicine 152(3); (September 1995)IM drop of 10-20%:Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, SCHS Studies No Raleigh, NC: North Carolina State Center for Health Statistics; 2002.1Women and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001.2Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1):3Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, SCHS Studies No Raleigh, NC: North Carolina State Center for Health Statistics; 2002.
16Infant Mortality, 2009 Rate per 1,000 live births Deaths 7.9 1,006 North Carolina7.91,006Onslow County6.928Nash County10.24Rockingham Co.10.511Bladen County10.6Wayne County13.222Dropping the IMR by up to 20% would translate into infant deaths prevented in your community.Keep in mind, the numbers for just one year are small. We need to look at trends over time to see true picture. Note that statewide rate for 5 year period of is 8.3 per 1,000 live births.Bladen: 4 deaths, rate: 29 for minorities, 0 for whiteNash: 4 deaths, rate: 15.4 for minorities, 5.8 for whiteOnslow: 28 deaths, rate: 6.9, for minorities 13.9, 5.4 for whiteRockingham, 11 deaths, 17.4 for minorities, 8.6 for whiteWayne, 22 deaths, 22.4 for minorities, 7.7 for whiteNC State Center for Health Statistics, NC Infant Mortality Report , 2009, Table 1.
17Low birth weight, 2004-2008 Percent of live births North Carolina 9.1 Onslow County7.9Wayne County9.2Rockingham County9.7Nash County10.1Bladen County10.3Remember – low birthweight is the birth outcome that is causally related with smoking during pregnancy. The rate is double in smokers vs. non-smokers is also statewide percent for 5-year period ofSee slide 15.NC State Center for Health Statistics, Trends in Key Health Indicators tables.
18Smoking in North Carolina 20% of females ages define themselves as a current smokerAges 25-34: 22%Ages 18-24: 19%16% of females ages say they smoke every dayHighest rates among women with low levels of educational attainment and/or high levels of povertyYoung women and women with low education levels and/or high poverty have the highest rates of smoking, unintended pregnancy and birth rates, according to BRFSS. (Self-report)Source:2009 NC Behavioral Risk Factor Surveillance System (NC BRFSS)NC Behavioral Risk Factor Surveillance System, 2009
19NC female adolescent tobacco use Female high school students who report using tobacco at least once in the last 30 days:20% (any tobacco)14% (cigarettes)59% of female high school smokers report living with someone who smokesSources:NC Youth Tobacco Survey, 2009NC Dept. of Health and Human Services, Feb 2010North Carolina Youth Tobacco Survey, 2009
20Smoking during pregnancy Nationally between 12-20% of all pregnant women report smoking during pregnancyCurrent clinical guidelines:“Whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. Clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.”According to the National Partnership to Help Pregnant Smokers Quit:The "5 A's" Counseling Method An easy-to-implement, evidence-based clinical counseling approach, the "5 A's", can double or even triple quit rates among pregnant smokers. This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American College of Obstetricians and Gynecologists. The approach is effective for most pregnant smokers, including low-income women, the group most likely to smoke during pregnancy.Studies show that a brief counseling intervention of 5-15 minutes, when delivered by a trained health care professional and augmented with pregnancy-specific self-help materials, can double or, in some cases, triple smoking cessation rates among pregnant women.Martin JA et al. Births: Final data for National vital statistics reports. Vol 52 no 10. National Center for Health StatisticsFiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services
21Smoking during pregnancy, 2005-2009 Number of womenPercentNorth Carolina70, 52912Bladen County34116Nash County759Onslow County1,82111Rockingham County1,10921Wayne County1,097The % is based on live births – not pregnanciesNC State Center for Health Statistics, NC Residents # and % of births to mothers that reported smoking prenatally
22Smoking in the perinatal period Time PeriodPercent of women reporting smokingPrior to pregnancy22During last 3 months of pregnancy13After pregnancy18Continuously (before, during & after)12*highest rates among younger women, less education and low incomePRAMS 2008
23Smoking after pregnancy 18% of women reported smoking after pregnancy in North CarolinaAges have the highest ratesOf women who reported smoking before pregnancy, then quitting during pregnancy, roughly half began smoking again 3-6 months postpartumPRAMS 2008
24Smokeless and non-cigarette tobacco use Increasing prevalence among young womenPose serious health risks for the woman and her fetusNot a safer alternative to smokingDoes not help smokers quitThere is NO safe form of tobaccoSome families have reported rubbing tobacco on their babies’ teething gums- this is not safe and not recommended.Source:Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists, Fiore, 2008Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services
25Smoking cessation during pregnancy: A maternal-child health best practice Despite the well-known health risks associated with smoking during pregnancy, many women continue to smoke even after learning they are pregnantIn a Cochrane review, successful smoking cessation during pregnancy resulted in a:20% reduction in the number of low birthweight babies17% decrease in preterm birthLumley J, Oliver S, Water E. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2000; CD
26A teachable momentWomen are more likely to quit at this time than any other time in their livesGenerally motivated to have a healthy babyBrief counseling sessions are proven to work but are generally not integrated into regular prenatal careCessation rates are 80% higher for women who receive counseling than for women who attempt quitting on their ownEven pregnancy specific, self-help materials alone increase cessation rates (vs. usual care)Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human ServicesFor further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.
27What providers can do Move beyond screening and recommendations Provide brief smoking cessation counseling and use pregnancy-specific self-help materialsUse the 5 A’s regularly with preconception, pregnant and post-partum patientsConnect patients with support such as the NC Quitline2008 Meta-analysis concludes that person-to-person psychosocial interventions are more effective than minimal advice to quitAlso, helping with transition for new moms to a new medical home and smoking supports if they have passed the postpartum period and no longer qualify for MedicaidFiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services
28Quotes from new moms“I would have appreciated more help to stop smoking during my pregnancy. I don’t think doctors emphasize that enough.”“I think doctors should advise patients to quit more aggressively.”PRAMS survey participants, 2007
29The 5 As Easy to implement Evidence-based Clinical counseling approach AskAdviseAssessAssistArrangeEasy to implementEvidence-basedClinical counseling approachEffective for most pregnant smokersAlso works preconceptionally and during the post-partum periodThis is an easy-to-implement, evidence-based clinical counseling approach, the "5 A's", can double or even triple quit rates among pregnant smokers.The PHS guideline approaches smoking as a chronic condition, similar to diabetes or hypertension, and stresses the need for regular, consistent counseling.This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American College of Obstetricians and Gynecologists. The approach is effective for most pregnant smokers, including low-income women, the group most likely to smoke during pregnancy. Its useful for young smokers and post-partum smokers as well.It follows a specific protocol or algorithm with some scripted material. The suggested language can be adapted to the clinician’s personal style and the patient’s individual needs.Note: The source for all the 5 A’s slides (29-49) is the ACOG CME module that is also included in the toolkits – participants are encouraged to read the entire booklet cover-to-cover as it is full of great information!ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human ServicesFor further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.
30ASK: Patients who are pregnant AdviseAssessAssistArrangeWhich of the following statements best describes your cigarette smoking?I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime.I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant.I smoke regularly now, about the same as BEFORE I found out I was pregnant. The recommendation is to systematically identify all tobacco users.13-26% of pregnant smokers may not disclose that they smoke when asked about it as part of a routine clinical interview. With pregnant patients the stakes are high in terms of getting smoking patients to disclose. The social stigma is also high and this affects women’s reluctance to disclose. Studies have confirmed that asking pregnant women each time you see them using a multiple choice format is most effective.Ask participants for some examples that demonstrate ineffective ways to screen for smoking status?Do you smoke?Are you a smoker?Do you consider yourself to be a smoker?Are you addicted to cigarettes?Now ask participants for some examples to start the conversation that will increase the likelihood of disclosure.We ask all our patients each time we see them to answer some questions about smoking….Please fill out this quick survey…..Which of the following best describes your cigarette smoking?Ask participants to split into pairs and practice asking a hypothetical pregnant patient about her smoking status. Walk through the room and give feedback to participants as you see them use the multiple choice script. A single yes/no question is not enough. Then after 3 minutes or so ask participants to switch roles and repeat the practice exercise.
31ASK: Patients who are not pregnant AdviseAssessAssistArrangeAsk if she has ever smoked, or smoked fewer than 100 cigarettes in her lifetimeAsk if she uses any of the following tobacco products: chewing or smokeless tobacco, little cigars or cigarillos, Hookah, snuff, melt in your mouth orbs, sticks or stripsAsk if someone smokes inside her house, in her car, around her, or at her workplaceFor patients that have never been pregnant you can use a variation of the pregnant smoker’s script: see 3 questions on slide.Consider asking about her smoking status as one her vital signsEmploy a universal identification system (ie: stickers, computer reminders)Keep in mind that adolescents can start smoking any time so its especially important to ask them at each visit. Adolescents can become addicted very quickly and are already established smokers by the time the have smoked 100 cigarettes.Ask participants to think of ways that they can think of ways to integrate the ASK question into everyday clinic routines? Record responses on a flip chart. Ensure the following are included:Program a reminder into the EMR system to screen for tobacco useUse the standardized multiple choice question to ask patients about smoking statusRecord smoking status as a vital sign in the patient record
32ASK: Patients who are postpartum or between pregnancies AdviseAssessAssistArrangeAsk the patient to choose the statement that best describes her smoking status:I have NEVER smoked or have smoked less than 100 cigarettes in my life.I stopped smoking BEFORE I found out I was pregnant and am not smoking now.I stopped smoking AFTER I found out I was pregnant and I am not smoking now.I stopped smoking during pregnancy, but I am smoking now.I smoked during pregnancy and I am smoking now.
33ASK Use a concerned, helpful tone when you ask about smoking AdviseAssessAssistArrangeUse a concerned, helpful tone when you ask about smokingUse a multiple choice formatUse either a written survey or clinical interviewAsking “Do you smoke” isn’t as effective as asking in a multiple choice format.Use a non-judgmental tone.Ask at multiple visits to your office.
34ADVISE Strongly urge all tobacco users to quit Use clear language AskAdviseAssessAssistArrangeStrongly urge all tobacco users to quitUse clear languageUse a strong toneUse a personalized messageThis is the portion of the counseling session where you make your recommendation to her, you share important information and you answer her questions all as part of starting the conversation about quitting.For pregnant women, provide clear, strong advice to quit with personalized messages about the impact of smoking on mother and fetus. Examples:My best advice for you and your baby is for you to quit smoking.It is important for you to quit smoking now for your health and the health of your baby, and I can help you.As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your baby and your own health. The clinic staff and I can help you.
35ADVISE: Link to motivational points AskAdviseAssessAssistArrangeTailor to her personal situationUse positive languageFocus on positive benefits of quittingUse appropriate motivational messagesTailor your advise to the patient’s situation and their responses to the ASK portion. Use positive language and focus on the positive benefits of quitting. Its important to not make the patient feel criticized or shamed, instead let her that you are aware of how hard this is and that you want to be a support to her.Use Demonstration Activity: Advise-Negative/Positive (Found in Training Guide)Its common for patients to minimize the risks and dangers smoking poses to infants and the long-term health risks for mothers.If patients know people that have had uncomplicated, healthy pregnancies while smoking, focusing on bad outcomes such as low birth weight or delivery complications would be ineffective. Its important to find points that would motivate them personally to quit.Use Demonstration Activity: Advise Using Motivational Points (Found in Training Guide)
36ADVISE: Acknowledge barriers AskAdviseAssessAssistArrange“I know I’m asking you to do something that takes a lot of effort, but my best advice to you (and your baby) is to quit smoking. I also see from your questionnaire that you have a history of bronchitis and asthma. Quitting smoking will help you feel better (and provide a healthier environment for your baby).”Acknowledging barriers to quitting while providing encouragement may make the patient more receptive to advice. Try to include a personal reason for quitting identified by the patient herself. Some examples to build from might include: she mentions that a family member developed lung cancer from smoking, a friend had a preterm baby and she smoked during pregnancy, she herself suffers from asthma, she herself can’t exercise comfortably because of feeling winded and coughing, etc.Use Demonstration Activity: Advise - Acknowledging Barriers (Found in Training Guide)
37ADVISE: Recent quitters to remain smoke-free AskAdviseAssessAssistArrangeCongratulate!Reiterate the importance of staying smoke free for her own health, any current or future pregnancies and any current or future childrenLet her know you will be asking about her smoking status in future visits
38ASSESS AskAdviseAssessAssistArrangeAssess the willingness of the patient to make a quit attempt within the next 30 daysFor women who are ready, move on to ASSISTFor women not ready to try quitting or commit to quitting, use the 5 R’sDepending on the next scheduled visit, or if she is pregnant- how far along the pregnancy is, make a decision together about setting a quit date within 30 days.
39The 5 R’s Relevance Risks Rewards Roadblocks Repetition It is unnecessary to address all the 5 Rs in a single visit. Consider 1 or 2 that are relevant depending on the patient’s comments in the ADVISE and ASSESS steps. Choose the appropriate R to first work on. For all these steps it is important for the woman to feel ownership of the process. Ask her with leading questions to identify the following:Relevance: What are the reasons to quit that are relevant to her situation? The point here is to identify what the motivational factors are for her and this will be different for each woman. For example, saving money, breathing easier during exercise which will help her lose weight, wanting a healthy baby, improving her odor and appearance to attract a new partner, etc.Risks: What are the risks or negative consequences of smoking for her, her baby, her children/family, etc.? This should be tailored to her stage of life. If she is pregnant, focus on the consequences for a developing fetus or baby. If the patient says that the last time she was pregnant she smoked and her baby was fine, you should spend more time here in “risks” and focus on education.Rewards: Here we ask the woman to imagine what life would be like for her and her loved ones if she quit smoking. Ask her to create a very specific list of reasons to quit- name names “If I quit smoking my 18 month old son might have less asthma and bronchitis infections.” Try to frame these in the “positive.”Roadblocks: We know a lot of smokers get caught up in the reasons why quitting hasn’t worked before, why it would be challenging now- the barriers. This is a time to problem-solve together and walk through some helpful patient materials and treatment options together. If her partner smokes and she sees this as a roadblock help her practice negotiating a smoke free zone for her home with her partner and identify a group of family and friends that will support her and help keep her busy when she is dealing with cravings.Repetition: Every time you see her ask about her smoking status and her readiness and willingness to quit. Plead your case each time and help her understand that every quit attempt brings her closer to quitting for good.
40RelevancePatient should discuss why quitting would be personally relevantHelp her identify motivational factors of her ownLink the motivational factor to her personal situationBe specificFor example, if she has children you would work with her to make a list of all the potential health risks to her children if she continues to smoke (ie: second and third hand smoke). You could also list the financial costs of her smoking and how that affects her ability to provide for her children. You might even list social stigma that the children face because of her smoking (their clothes smell like smoke, she leaves children’s events to smoke, other parents disapprove and this affects their friendships). And finally you might list her children’s psychological fears of her dying early.Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.
41Risks Ask her to list potential negative consequences of smoking If patient is unaware of risks, this is a teachable moment- share informationTailor risks for where she is in lifeNo pregnancies yetPregnantPostpartumBetween pregnanciesAlthough you may not want to quit right now or are not ready to quit, please share what you have heard about …..(Choose one or more of the following to discuss with the patient, making it relevant to her current life situation.)Smoking and pregnancyEffects of smoking around babies and young childrenEfects of smoking when children live with youLong term effects on your own health and mortalityFinancial costs of smokingOf special note is some women think that if they have already had a healthy baby while smoking that the risks are overstated or don’t apply to her. Or, some women know other women who smoked during pregnancy and had healthy babies and this is their frame of reference when they talk about preconception health. For these women its important to explain that every pregnancy is different and that her body changes as well as she gets older. Smoking longer may have impact the development of a chronic disease that could impact a future pregnancy and delivery. The absence of complications in a previous pregnancy (or another woman’s pregnancy) does not guarantee future pregnancies free of problems.
42RewardsAsk the patient to think about how quitting might benefit her and her familyGive her examples tailored to her situationUse the patient’s history and comments about her smoking behavior to create a checklist of factors that will increase her motivation to quitFor example, a pregnant woman’s checklist might include:Bringing the baby home from the hospital with herBaby being a healthy weight, born full term and having no breathing problemsLess time at medical appointmentsSaving moneyPleasing family and friendsHealthier skin, smelling betterProtecting a child with asthma or from asthma\
43Roadblocks Ask the woman what she thinks her barriers to quitting are Talk through problem solving strategiesDemonstrate toolsRefer back to the group brainstorm about Barriers and Coping Strategies.
44RepetitionAt each subsequent appointment ask if she has changed her mind about trying to quitExplain that many people have to try more than once to quit and that each new attempt to quit increases the likelihood of quitting for goodSmoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.
45ASSIST Set a quit date Use a direct approach AskAdviseAssessAssistArrangeSet a quit dateUse a direct approachAvoid dates of significant events such as a birthday or anniversaryUse a Quit Contract or record the quit date in a patient education materialYou need to choose a quit date so that you can be prepared. Would it be easier to quit on a weekday or a weekend?
46ASSIST Assess/arrange for support in the smoker’s environment AskAdviseAssessAssistArrangeAssess/arrange for support in the smoker’s environmentProvide pregnancy or post-partum specific, self-help smoking cessation materials & review with patientHelp patient envision and have a plan for cravings, withdrawal symptoms and social situationsAsk patient to prioritize 1 or 2 concerns or potential barriersProvide reinforcement through a congratulatory letter or phone callThis is the “doing” part of the 5As.Help the patient identify people in her own environment who can help and encourage her to quit. The patient’s partner may not be the most likely choice o provide support. Ask her about others in her family and social circle who can provide encouragement and support (ie: distraction activities like talking on the phone, going for walks, etc.).Patient education materials that reinforce the counseling in the ASSIST step are helpful. For pregnant patients, pregnancy-specific materials have been found to improve quit rates compared to interventions without self help materials.Review some patient education tools from Section 4 of the Tool Kit, especially the Quitline information.Problem solving assistance can be spread over several visits and the coaches from the Quitline can also help with this. Patients may feel overwhelmed by a number of potential barriers to quitting. Helping her identify 1 or 2 areas to focus on and provide problem-solving techniques or materials to help address.Support both within the health care office and in the patient’s environment are important parts of the ASSIST step. Office staff who interact with patients should keep a positive attitude concerning smoking cessation to encourage and support ANY attempt to stop smoking.
47ASSIST Make a referral to the NC Quitline: 1-800-QUITNOW AskAdviseAssessAssistArrangeMake a referral to the NC Quitline: QUITNOWTrained cessation coaches have protocols for pregnant women and adolescents/young adultsPatients can also text COACH to to receive cessation advice via their mobile phonesFree, 8am-3am, 7 days a weekFax referral service speeds up the processThe Quitline has proactive coaches who can initiate calls to patients who are ready to quit.See section 4 in binder: p. 5 of the North Carolina smoking cessation resources guide – here you’ll find specific information about how to refer to the Quitline. Or go to and click on “For medical professionals.” There is also a consumer section of the website.
48Assisting heavy smokers Pregnant women who smoke more than a pack a day and are unable to quit after the 5As and the 5Rs may need more helpThe NC Quitline is helpful for heavy smokersIntensive behavioral counseling may be necessary via referral
49ARRANGE Make follow-up visits AskAdviseAssessAssistArrangeMake follow-up visitsRepeatedly assess smoking status and, if she is a continuing smoker, encourage cessationFor patients trying to quit these visits should allow time to:Monitor progressReinforce the steps toward quittingPromote problem solving skills to prevent relapse or quickly recover from relapsePatients who are still smoking should be encouraged to quit at every opportunity. If you are seeing the patient only through the postpartum period help her establish a medical home for herself to continue preconception and interconception care, including smoking cessation services.Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.
50Postpartum relapse45%-70% of women who quit smoking during pregnancy relapse within 1 year of deliveryRelapse may be delayed or avoided among women who receive smoking cessation counseling during the postpartum periodFor this reason it’s important to use the post-partum check up visit to assess smoking status and refer to a primary care provider as necessary, specifically to continue postpartum smoking assessments and intervention with the 5 A’s.US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon GeneralMcBride CM et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:
51Preventing postpartum relapse Good documentationUse the 5 A’s at the postpartum visitUse positive language to counselReiterate messages of:Risks to babies and children from smoke exposureMake your home a SMOKE FREE ZONEPraise for efforts to quit and stay quitKeeping track of smoking status and smoking history with prompts to ASK at every interaction.
52Treating postpartum relapse Reassure and encourage her to try againAsk her to:Quit immediately and put it in writingGet rid of all smoking materialsTalk about what worked initially and what may have led to the relapsePrioritize smoking cessation over post-partum weight loss
53Treating postpartum relapse EncouragementReview triggersRefer back to NC QuitlineRefer back to self help materialsBreastfeeding should always be encouragedIf she is not breastfeeding, consider prescribing a pharmacologic aidEnsure that the patient has a medical home for follow up beyond the postpartum periodWe’ll discuss breastfeeding and pharmacologic aids in a moment…Nicotine replacement therapies pass into breast milkThere is limited information available about the effects on infants of the use of buproprion and varenicline during lactation.See notes on slide 56 for more info on this point.
54ActivityTrainer: Choose appropriate activity from Trainer’s Guide to model or practice 5 A’s counseling in small groups
55When the 5 A’s approach isn't enough Referral for intensive counseling with a specialized providerPharmacotherapy options*Nicotine replacementGum, patches, lozenges, nasal spray and inhalers*Careful consideration; benefits must outweigh the risks*Many experts do not consider using these as an option during pregnancyThe US Public Health Service Guidelines state that behavioral interventions should always be the first line of treatment for pregnant smokers. The use of pharmacotherapy during pregnancy, including over the counter nicotine replacement and prescription oral medications is controversial. Also, it is not clear that it is effective during pregnancy.The guideline also advises providers to carefully consider use of medications used to treat tobacco dependence (nicotine replacement and bupropion) for pregnant women because they have not been tested for safety and efficacy during pregnancy.Pharmacotherapies should be used only for pregnant women who smoke heavily and are unable to quit using counseling methods, and only when the potential benefits and likelihood of quitting are likely to outweigh the potential risks. Many experts do not advise using them at all during pregnancy.The FDA has placed a black-box warning on all antidepressants (Bupropion)and varenicline as their use increases the risk of suicide, particularly among adolescents and young adults. Clearly, this is not a good option for the target patient population that this training is addressing.ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.
56Pharmacotherapy and lactation Nicotine replacement therapies pass into breast milkThe highest dose (21 mg) = 17 cigarettes in breast milk14 mg and 7 mg result in much lower amounts of nicotine passing into breast milkGum and lozenges pass variable amounts depending on how much is chewed and frequency of useBuproprion may reduce milk supplyThere is limited information available about the effects on infants of the use of buproprion and varenicline during lactation.Please refer to the chart on page 6 of the Practice Bulletin, December You Quit Two Quit. Smoking Cessation: An Essential Maternal Child Health Intervention for more information. Found in your binder – section 3.Additional resources found at:Nicotens.LACTMED: Drug and Lactation Database. National Institutes of Health. Available from:Buproprion and Chantix. Medication and Mothers Milk Discussion Forum. Available from:ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.
57Pharmacotherapy for non-lactating postpartum women Good option for those women for whom behavioral interventions have not been effectiveAll forms of nicotine replacement increase the success of a quit attempt by 50%-70%Source: Practice Bulletin, December YouQuitTwoQuit. Smoking Cessation: An Essential Maternal Child Health Intervention.Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotene replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No. CD pub3.Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No. CD pub3You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.
58Reimbursement for smoking cessation counseling Not one-size-fits-all: Each facility should investigate reimbursement options to maximize their payments for this important serviceFacilities such as a health department or a hospital generally use a facility rateFacilitate a conversation about how various providers and facilities are billing for smoking cessation services (to both Medicaid and private insurers).
59Medicaid covers smoking cessation counseling Smoking cessation counseling CPT codes:99406 – Intermediate visit (3-10 minutes)99407 – Intensive visit (> 10 minutes)An appropriate tobacco-related diagnosis, such as ICD-9 code (tobacco abuse), must be filed in addition to the Evaluation and Management code and submitted with the CPT codeFor more information, go to:As of January 1, 2009, physicians, nurse practitioners and health departments can receive reimbursement for the following Smoking Cessation Counseling CPT codes:99406 – Intermediate visit (3-10 minutes)99407 – Intensive visit (> 10 minutes)An appropriate tobacco-related diagnosis, such as ICD-9 code (tobacco abuse), must be filed in addition to the Evaluation and Management code and submitted with the CPT code. In addition to physicians, nurse practitioners, and health departments, these codes can be billed “incident to” the physician by the following professional specialties: licensed psychologists, licensed psychological associates, licensed clinical social workers, licensed professional counselors, licensed marriage and family counselors, certified nurse practitioners, certified clinical nurse specialists, licensed clinical addictions specialists or certified clinical supervisors. Practitioners must continue to follow the guidelines for services provided “incident to” the physician. Refer to the article tiled Modification in Supervision When Practicing “Incident To” a Physician in the October 2008 general Medicaid bulletin for additional information.For more information, please see the January 2009 NC Medicaid Bulletin: http://www.dhhs.state.nc.us/dma/bulletin/0109bulletin.htmA copy of the relevant sections of this bulletin is found in your binder at the end of Section 3.
60Creating a supportive health care facility environment Implement a tobacco user identification systemDedicate specific staff to provide tobacco cessation treatmentEducate and gain input from staff about implementing tobacco cessation servicesAssign one person to coordinate and monitor implementationTrain staff on 5 A’sAdapt procedures to your specific settingExtend postpartum tobacco cessation services to 12 months post-partumInvite staff to participate in the planning process. Provide and overview of the 5As (not a training) at the beginning and emphasize that encouragement from staff members has been shown to help patients quit smoking.Use handout for small group work here – see module at a glance and training materials.Source:Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.
61Summary: 5 A’s Ask: Systematically identify all tobacco users AdviseAssessAssistArrangeAsk: Systematically identify all tobacco usersAdvise: Strongly urge all tobacco users to quitAssess: Determine willingness to quitAssist: Set a quit date, materials, problem solveArrange: Make plans to monitor smoking status, provide reinforcement, support and encouragementThe 5 As works best when:There is a tobacco user identification system in placeStaff have all been educated and collectively are “on board” in terms of using encouraging, motivational tones with patientsStaff have been assigned rolesPatient materials and referral services are on hand
62SummaryIdentify and counsel young women who use tobacco and are at risk for pregnancyThe 5 A’s approach is an effective, evidence-based method of achieving smoking cessation during before, during and after pregnancyMaintaining cessation in the post-partum period is challenging and post-partum relapse is commonPostpartum relapse can be prevented with proper postpartum screening, 5 A’s approach, and extended cessation services to 12 months postpartum